Errors as Opportunities

As I listened to our reflections moment about releasing the newly hatched sea turtles into the big open ocean I definitely was excited because my favorite animals are sea turtles. They are slow, methodical, and majestic looking as they glide through the open waters. Their soft insides are protected by their hard outer shell and I have always identified with them. Water is source of calmness and serenity for me. I feel at peace there. 

    

However, the hard outer shell is needed because there are challenges that sea turtles face. Even with this hard outer shell, if they are not careful or aware, things like boats can injury them or even worse kill them.

Even as they are making their way to the ocean for the first time, they are susceptible to harm. The instinct of the guest, just as a mother would, was to protect and carry them. It is often as parents where we rob our children of their own personal growth. Carr (2016) clearly shows that it is through this early struggle that they gain their strength to sustain them as they navigate the ocean for the next 100 years. Much like our children, we have to guide, maintaining those healthy boundaries but also let them struggle so they can develop resilience, perseverance and sometimes we just have to learn lessons the hard way. Making mistakes is sometimes the best teacher. The most successful people often have the highest rate of failures.

                                

                                    

Healthcare is a little different though. We want to make sure that we don't sit idly by while people are making mistakes and not have a culture where we ADMIT them, LEARN from them and PREVENT them. Leadership has to be able to embrace the vulnerability of everyone making mistakes and encourage reporting of these errors without fear of punishment and utilize it as and educational opportunity. My facility has been a High Reliability Journey for over a year now. It has ushered an environment where staff on the frontlines now actually encourage each other to report great catches, near misses and even adverse events. They are not hesitant to report on themselves. They see this as an avenue and feel safe to discuss what happened and where things could have or did go wrong. We are able to utilize safety issues that occurred and great catches alike to spread education and empowerment to create a patient-centered and safe culture. Our reporting system is a Joint Patient Reporting System (JPSR), that allows us to facilitate the correct information to the correct department in a timely manner. These mistakes or errors are discussed in our daily huddles as safety issues to bring about awareness and get other perspectives on the processes involved to prevent them from happening again. 

 ~No one goes into healthcare wanting to harm a patient~

However,

                                     

Albert et al., (2022, p.373) set the stage for the 7 critical elements needed for a Safety Culture.

1. Just Culture
2. Learning
3. Teamwork
4. Communication
5. Evidence-based practice
6. Patient-centered care
7. Leadership

There must be a commitment from leadership to foster and promote this non-punitive environment and encourage an environment of education and process issues over individual blame. We in healthcare have been working on transforming healthcare delivery to be preoccupied with failure to prevent it from happening from a process, structure, and outcomes, Donobedian model. Healthcare is a very complex system and it sets workers up for risky behaviors, so how fair is it that we would also blame them for a system that was set up for failure?

                                            

This picture reminds me of how things in healthcare have been for so long.

We all knew that we were not ok and that the system was not ok.

BUT, no one said anything!

That is NOT ok!

This is a system error versus an individual error environment we are moving towards. There has to be trust in leadership to not punish also. "Identifying and understanding the source of mistakes or errors is an essential first step in identifying breakdowns and opportunities for improvement" (Albert et al., 2022, p. 373). How are we able to find out about the issues once we establish a safe culture for the employee to report?

The safety reporting culture has to be created and workers have to,

                                            to stop the line 

                        

                                       

This happens with out fear of punishment, it empowers people and places value on the worker and the patient. As a leader of an inpatient care unit I know this all to well. If they do not trust you or feel safe with you they will not report to you a well known issue because their instinct is to protect their job, livelihood and own family. This is not the culture I want for myself, as I have been a patient many times or for my family. Throughout the healthcare administration program, I have learned that the biggest issue is rising costs in healthcare and one of the biggest contributors is errors that create extended length of stays, which is costly, or additional treatments needed for injuries sustained. Creating this culture of reporting and safety to identify and problem solve together not only provides the mission of healthcare to do ZERO HARM, it also helps decrease costs if we are preventing these errors from occurring in the first place.

The biggest issue in any relationship is communication. The lack of communication is the source of so many misunderstandings, mistakes and breakdowns between relationships.

Healthcare should be a beautiful environment where communication is the source for all things good. Singing melodiously like the song of a bird waking you to a new spring day with all of the hope for healing and everything that is right in this world.

                                                   

Our healthcare system is not perfect, however, with continued efforts and communication, there is hope and improvement that is seen.

References

Albert, N., Pappas, S., Porter-O'Grady, T., & Malloch, K. (2022). Quantum leadership: Creating sustainable value in health care (6th ed.). Burlington, MA: Jones & Bartlett Learning, LLC.

Carr, J. (2016). A secret to parenting that no one tells you: The strength is in the struggle. https://annvoskamp.com/2016/09/a-secret-to-parenting-that-no-one-tells-you-the-strength-is-in-the-struggle/